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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />CERS = California Environmental Reporting System, ICC = International Code Council, <br />ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br />Page 1 of 5 <br />TYPE OF ACTION Installation Repair 6 Month 36 Month <br />CERS ID <br />10181511 <br />Test Date <br />09/1 /2024 <br />Facility Name <br />Boyett Petroleum #98 / Kwik Serv <br />Facility Address <br />2501 Jackson Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <br />Company Performing the Test <br />CGRS, Inc. <br />Phone <br />(916) 991-1100 <br />Mailing Address <br />5444 Dry Creek Road; Sacramento, CA. 95838 <br />Service Technician Performing Test <br />Leo Rangel <br />Contractor/Tank Tester License Number <br />CSLB#803616 <br />ICC Number <br />8711887 <br />ICC Expiration Date <br />07/07/2025 <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />Triangle Manufacturing 5000w Sump Tester Cert. #TMI-167 08/21/2027 <br />Modern Welding 09/13/2026 <br />S. Bravo Systems Cert. #2020-2929929 12/01/2026 <br />NOV Fiberglass Systems 11/29/2024 <br />Test Procedures Used Components Tested <br />RP-1200 / Cal CUPA Form Tank Annular <br />I hereby certify that the secondary containment was tested in accordance with California <br />Code of Regulations, title 23, division 3, chapter 16, section 2637; that required supporting <br />documentation is attached; and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature: <br />Leo Rangel <br />Date <br />09/1 /2024 <br />Total # of Pages <br />6 <br />1. FACILITY INFORMATION <br />2. SERVICE TECHNICIAN INFORMATION <br />3. TRAINING AND CERTIFICATIONS <br />4. TEST PROCEDURE INFORMATION <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST